Rheumatoid arthritis of the cervical spine.

BACKGROUND CONTEXT: Rheumatoid arthritis affects over 2 million patients in the United States. It is the most common inflammatory disorder of the cervical spine. The natural history is variable. Women tend to be more commonly involved than men. Atlantoaxial instability is the most common form of cervical involvement and may occur either independently or concomitantly with cranial settling and subaxial instability. Cervical spine involvement can be seen in up to 86% of patients and neurologic involvement in up to 58%. Myelopathy is rare but when present portends a poor prognosis. What is frustrating for clinicians treating these patients is that pain cannot be equated with instability or instability with neurologic symptoms. The goal is to identify patients at risk before the development of neurologic symptoms. Both radiographic and nonradiographic risk factors play an important role in the surgical decision-making process. PURPOSE: We will describe the current concepts in rheumatoid arthritis of the cervical spine. Emphasis is placed on the natural history, anatomy, pathophysiology and decision-making process. STUDY DESIGN: A review of the current concepts of rheumatoid arthritis of the cervical spine. METHODS: MEDLINE search of all English literature published on rheumatoid arthritis of the cervical spine. RESULTS: Rheumatoid arthritis of the cervical spine was first described by Garrod in 1890. The prevalence has been estimated to be 1% to 2% of the world's adult population. Despite its prevalence, the etiology of rheumatoid arthritis remains unknown. Because of its potentially debilitating and life-threatening sequelae in advanced disease, rheumatoid arthritis in the cervical spine today remains a high priority to diagnose and treat. CONCLUSIONS: Many aspects of the natural history and pathophysiology of the rheumatoid spine remain unclear. The timing of operative intervention in patients with radiographic instability and no evidence of neurologic deficit is an area of considerable controversy. Continued surveillance into the natural history of the rheumatoid spine is required.     

Rheumatoid arthritis of the cervical spine

There is a high incidence of cervical involvement in patients with rheumatoid disease. Early evaluation of the neck, close follow-up with dynamic radiographs of the cervical spine, and careful neurological assessment are important in the care of these patients. Surgical stabilization should be considered early even in the absence of neurological findings when significant instability is noted since outcome is related to preoperative neurological function. The type of fusion performed is determined by a careful assessment of the location of instability, patient factors, and the experience of the surgeon with various techniques. The type of postoperative immobilization should be decided on an individual basis depending on the quality of fixation achieved at surgery. Patients must be observed closely in the postoperative period for development of early complications and followed-up for the appearance of pseudarthrosis or late instabilities.     

Rheumatoid arthritis in the cervical spine

The cervical spine often becomes involved early in the course of rheumatoid arthritis, leading to three different patterns of instability: atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. Although radiographic changes are common, the prevalence of neurologic injury is relatively low. The primary goal of treatment is to prevent permanent neurologic injury while avoiding potentially dangerous and unnecessary surgery. Strategies include patient education, lifestyle modification, regular radiographic follow-up, and early surgical intervention, when indicated. Magnetic resonance imaging is indicated when neurologic deficit (myelopathy) occurs or when plain radiographs show atlantoaxial subluxation with a posterior atlantodental interval < or =14 mm, any degree of atlantoaxial impaction, or subaxial stenosis with a canal diameter < or =14 mm. Surgery should be considered promptly for any of the following: progressive neurologic deficit, chronic neck pain in the setting of radiographic instability that does not respond to nonnarcotic pain medication, any degree of atlantoaxial impaction or cord stenosis, a posterior atlantodental interval < or =14 mm, atlantoaxial impaction represented by odontoid migration > or =5 mm rostral to McGregor's line, sagittal canal diameter <14 mm, or a cervicomedullary angle <135 degrees.     

Rheumatoid arthritis in the cervical spine

Rheumatoid arthritis causes synovitis in the cervical spine and injures skeletal structures at any level. Subluxations occur with pain and spinal cord dysfunction. Subluxations are common; neurological problems are less so, but death from subluxations is not common. However, once myelopathy is established, the natural history is poor. Advances in radiologic imaging through computed tomography and magnetic resonance imaging greatly assist anatomic assessment. Neurologic deterioration and pain are indications for surgery. Preoperative skeletal traction is often required to align the spine, and fusion techniques are used for stabilization.     

颈椎类风湿性关节炎及其手术治疗

类风湿性关节炎是一种以关节病变为主的慢性全身性自身免疫性疾病 ,凡构成关节的各种组织如滑膜、软骨、韧带、肌腱以及相连的骨骼都可发生病变。最初表现为对称性多关节炎 ,主要侵犯手、腕和足的小关节 ,然后累及其他关节。当病变发展到一定程度时 ,常可累及脊柱尤其是颈椎。据统计 ,类风湿性关节炎最常受累的部位为跖趾关节 ,其次为掌指关节和颈椎。文献中报道类风湿性关节炎患者中颈椎受累的比例为2 5 %～ 80 %不等。颈椎类风湿性关节炎又称类风湿性颈椎炎 ,由Ｇａｒｒｏｄ于 1890年最早报道 ,但至今临床上仍不乏误诊漏诊者 ,其治疗选择…     

Rheumatoid arthritis of the cervical spine: current techniques for management

The incidence of rheumatoid arthritis in the European and North American population is significant. Rheumatoid arthritis can result in serious damage to the cervical spine and the central neuraxis, ranging from mild instability to myelopathy and death. Aggressive conservative care should be established early. The treating physician should not be lulled into a false sense of security by reports suggesting that cervical subluxations are typically asymptomatic [76-78]. Gradual spinal cord compression can result in severe neurologic deficits that may be irreversible despite appropriate surgical intervention when applied too late. [figure: see text] The treatment of rheumatoid disease in the cervical spine is challenging. Many details must be considered when diagnosing and attempting to institute a treatment plan, particularly surgical treatment. The pathomechanics may result in either instability or ankylosis. The superimposed deformities may be either fixed or mobile. The algorithm suggested by the authors can be used to navigate through the numerous details that must be considered to formulate a reasonable surgical plan. Although these patients are [figure: see text] frail, an "aggressive" surgical solution applied in a timely fashion yields better results than an incomplete or inappropriate surgical solution applied too late. When surgical intervention is anticipated, it should be performed before the development of severe myelopathy. Patients who progress to a Ranawat III-B status have a much higher morbidity and mortality rate associated with surgical intervention than do patients who ambulate. Although considered aggressive by some, "prophylactic" stabilization and fusion of a [figure: see text] relatively flexible, moderately deformed spine before the onset of severe neurologic symptoms may be reasonable. This approach ultimately may serve the patient better than "observation" if the patient is slowly drifting into a severe spinal deformity or shows signs of early myelopathy or paraparesis.     

上颈椎类风湿关节炎与脊髓损伤

目的 对颈椎类风湿关节炎累及枕颈部或寰枢椎的患者行颈后路植骨融合内固定治疗。方法 对本组17例颈椎类风湿关节炎的患者（神经功能损害按Ranawat分级：Ⅱ级5例、ⅢA级10例、ⅢB级2例）,行颈后路植骨融合内固定术,其中4例垂直半脱位（VS）患者和4例难复性寰枢椎半脱位（AAS）患者行枕颈减压融合内固定术、9例可复性或复位效果较好的AAS患者行钛缆寰枢椎融合固定术。结果 随访1．5～7．5年（平均3．5年）,17例均获骨性融合,15例患者的神经功能获不同程度改善,2例虽无改善但亦无神经损伤加重。结论 早期寰枢椎或枕颈部稳定手术,似可有效减缓颈椎类风湿关节炎（RA）的炎症破坏过程;同时发现RA病程仍呈进行性,但术后17例患者的齿突周围血管翳较术前明显减小。     

Rheumatoid arthritis: evaluation and surgical management of the cervical spine

BACKGROUND CONTEXT: Rheumatoid arthritis is a debilitating polyarthropathic degenerative condition. Eighty-six percent of patients with rheumatoid arthritis have cervical spine involvement. Often these lesions are clinically asymptomatic or symptoms are erroneously attributed to peripheral manifestation of the patient's rheumatoid disease. Because these lesions are common and missed diagnosis can result in death, early recognition is vital. PURPOSE: The purpose of this literature review is to identify common lesions present in the rheumatoid neck and review diagnostic methods as well as treatment options for those requiring surgical intervention. STUDY DESIGN: A review of the English medical literature with focus on more recent studies on the presentation, diagnosis, management, surgical treatment and clinical outcomes of rheumatoid arthritis of the cervical spine. METHODS: A comprehensive literature review of the English medical literature obtained through Medline up to November 2003 was performed identifying relevant and more recent articles that addressed the presentation, evaluation, surgical management and outcomes of rheumatoid patients with cervical spine involvement. RESULTS: If left untreated, a large percentage of rheumatoid patients with cervical spine involvement progress toward complex instability patterns resulting in significant morbidity and mortality. Once myelopathy occurs, prognosis for neurologic recovery and long-term survival is poor. In properly selected patients, anterior and/or posterior cervical procedures can prevent neurologic injuries and preserve remaining function. CONCLUSION: Cervical spine involvement in the rheumatoid patient is common and progressive. Early diagnosis and treatment is imperative; however, surgical intervention should be considered carefully because associated morbidity and mortality is high.     

Rheumatoid arthritis of the thoracic and lumbar spine

We report seven cases of patients with seropositive rheumatoid arthritis in whom involvement of the thoracic and lumbar vertebrae occurred. Histological corroboration is presented in four. Pathological lesions comprised various combinations of paravertebral joint erosions, erosive discitis, anteroposterior and rotatory instability, major lumbar nerve root compression, and vertebral collapse. Specific radiological features are presented, enabling a distinction to be made between pure degenerative spondylosis and rheumatoid spondylitis. We submit that subcervical rheumatoid spondylitis is commoner than is generally believed, though less common than rheumatoid involvement of the cervical spine.     

Rheumatoid arthritis of the cervical spine--clinical considerations

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder affecting multiple organ systems, joints, ligaments, and bones and commonly involves the cervical spine. Chronic synovitis may result in bony erosion and ligamentous laxity that result in instability and subluxation. Anterior atlantoaxial subluxation (AAS) is the most frequently occurring deformity, due to laxity of the primary and secondary ligamentous restraints. Additional manifestations of RA include cranial settling, subaxial subluxation, or a combination of these. Although clinical findings can be confounded by the severity of multifocal joint and systemic involvement, a careful history is critical to identify symptoms of cervical disease; serial physical examination is the best noninvasive diagnostic tool. Thorough physical and neurologic examinations should be performed in all patients and serial functional assessments charted. Radiographs of the cervical spine with lateral flexion-extension dynamic views should be obtained periodically and used to "clear" the cervical spine before elective surgery requiring general anesthesia. Advanced imaging, such as magnetic resonance imaging (MRI) or myelography and computed tomography (CT), may be necessary to evaluate the neuraxis. Early initiation of pharmacotherapy may slow progression of rheumatoid cervical disease. Operative intervention before the onset of advanced myelopathy results in improved outcomes compared to the surgical stabilization of patients whose conditions are more advanced. A multidisciplinary approach involving rheumatology, surgery, and rehabilitation is beneficial to optimize outcomes.     

The degenerative cervical spine: pathogenesis and rehabilitation concepts.

The degenerative process associated with spondylosis in the cervical spine has been reviewed. The two compressive syndromes commonly associated with spondylosis, radiculopathy and myelopathy, are briefly reviewed. Except for more severe, multilevel degenerative changes producing neurologic compromise, correlation between degenerative changes and patient symptoms or functional limitations is generally poor. A conceptual scheme for guiding rehabilitation of mechanical neck pain, based on irritability level and the effects of mechanical stress on symptoms, is proposed. Further research is required to test the reliability and validity of categorization schemes like the one proposed. Such schemes based on history and effects of mechanical stresses, rather than solely on degenerative radiographic findings, are necessary to classify patients in meaningful ways that help guide specific rehabilitation strategies and tactics. When meaningful classification schemes exist, treatments matched with specific categories of dysfunction can be tested for effectiveness.     

Delayed diagnosis of cervical spine injuries.

Over a 32-month period, the cases of all patients with multiple injuries on whom cervical spine roentgenograms (CSRs) were obtained during blunt trauma evaluation in a trauma center were reviewed to determine the incidence, outcome, and clinical consequence of delayed diagnosis of cervical spine injuries. A total of 1,331 patients had CSRs following blunt injury. Sixty-one (4.6%) of the patients had documented cervical fractures or dislocations. The patients were seriously injured (mean Trauma Score, 12; mean Glasgow Coma Scale score, 11; and mean Injury Severity Score, 30.3). Eleven of the patients died in the trauma room; 9 with fatal atlantoaxial dislocation. Of the 50 survivors (81.9%), neurologic deficits were present in 15 (30%), and 8 of those had complete spinal cord injuries. The diagnosis of the cervical spine injury was made during the initial evaluation in 56 of the 61 patients (91.8%). Five patients had delayed recognition of their cervical spine injury (2-21 days). The reason for the delay was incomplete CSRs in all patients, despite multiple views (up to 13). The missed injuries occurred in patients in whom complete visualization of the spine was most difficult (i.e., severe degenerative arthritis of the cervical spine in two patients; previous cervical fractures in one patient; instability during resuscitation in one patient). Radiologic misinterpretation occurred in one patient. The diagnosis of cervical spine injury was pursued because of persistent neck pain in two patients, and the development of subtle neurologic findings in three. The neurologic deficits in the three patients resolved.(ABSTRACT TRUNCATED AT 250 WORDS)     

The cervical spine in juvenile chronic arthritis.

BACKGROUND CONTEXT: In patients with juvenile chronic arthritis (JCA) the cervical spine is often affected, leading to pain and functional limitations. PURPOSE: To describe the frequency of the radiographic abnormalities in the cervical spine of a large series of patients with JCA, examined after skeletal maturity. STUDY DESIGN: Consecutive patients with JCA, who had cervical spine radiographs available taken at adult age (>18 years) were included in the study from one outpatient clinic and one rheumatology ward in the Rheumatism Foundation Hospital, Heinola, Finland. PATIENT SAMPLE: The series consisted of 159 patients fulfilling the diagnostic criteria of the European League Against Rheumatism for JCA. OUTCOME MEASURES: Evaluation of cervical spine radiographs for inflammatory changes. METHODS: Inflammatory changes in the cervical spine radiographs were measured as well as the size of the fourth cervical vertebra. Patient records were studied. The statistical analysis was calculated by Student's t-test or Mann-Whitney U test. RESULTS: In 98 cases (62%) some inflammatory changes were detected in the cervical spine. Apophyseal joint ankylosis was noted in 65 patients (41%), anterior atlantoaxial subluxation in 27 (17 %) and atlantoaxial impaction in 39 (25 %). The fourth cervical vertebra was abnormally small in 41 patients (26%). CONCLUSIONS: Radiographically, the most frequent inflammatory change in the cervical spine of patients with JCA was apophyseal joint ankylosis at multiple levels. Atlantoaxial impaction and anterior atlantoaxial subluxation were typical of the upper cervical spine. Clinically, these changes tend to limit neck movements. A small C4 vertebral body was seen in patients with early disease onset and short body stature.     

Operations for the unstable cervical spine in rheumatoid arthritis

Sixteen patients with seropositive rheumatoid arthritis were operated on for subaxial subluxations. Four of the patients had slight, but progressive, tetraparesis, and 5 had severe or total tetraparesis; they were operated on 1-4 months after the first signs. Seven patients were treated for severe neck and shoulder pain. Nine patients had subluxation at the C3-4 level, the most common site, and 3 patients also had an atlantoaxial subluxation. Patients with cord compression were treated with posterior laminectomies and fusions that relieved the tetraparesis. Two patients died during the early postoperative period: 1 of a cardiac infarction and the other of pneumonia. During 4 (1.5-9) years' follow-up, 3 patients had new subluxations at other levels.     

The upper cervical spine. Symptomatology, clinical diagnosis and therapy of functional disorder

Due to the closely related trigeminus nuclei, segmental functional disorders in the suboccipital area cause--in addition to local neck pain--frontoparietal and retro-orbital pain that can also irradiate to the upper and lower jaw. In addition, tendomyoses with trigger points and difficulties in swallowing may occur in the anterior part of the neck. In order to differentiate between hypomobility, hypermobility or instability, clinical diagnostics requires specific examination of each particular segment in accordance with its biomechanics. Once the nature of the functional disorder is defined, the whole repertoire of therapeutic measures can be applied, with segment-oriented manual techniques being the most efficient. In cases of persisting and recurrent disturbances, rehabilitation must be completed by regular back exercises and optimal ergonomics.     

Current concepts in asthma therapy.

Attacks of asthma can be precipitated in susceptible individuals by a variety of stimuli acting through immunological or non-immunological pathways. The pathological changes in the lung which characterize asthma include bronchoconstriction, mucosal oedema and tenacious secretions. A logical approach to therapy is outlined, based on intervention at successive sites along the trigger-to-target organ response pathway.     

Surgery of the cervical spine in rheumatoid arthritis. Diagnostics and indication

The cervical spine is often affected in rheumatoid arthritis. Beside destructive changes, instabilities can occur, mainly in the upper cervical spine. Typical symptoms are missing so that routine x-ray examinations are needed to prevent severe consequences up to death. AP/lateral cervical spine x-rays and lateral functional x-rays are the standard diagnostic tool. Depending on the findings, further neurological examination and MRI must be initiated. Aim is the early recognition, respectively prevention of myelopathy. Therapy includes stage dependent conservative and surgical measures.